While measuring physical, mental, and social health as defined by the World Health Organization (WHO), the basis of measurement is in terms of Determinants. Recently with the advent of health promotion activities, the emphasis is on enabling individuals, groups, and societies to have control on these Determinants. To measure the spiritual health, the 4 th Dimension, a Spiritual Health Scale consisting of 3 Domains, 6 Constructs, and 27 Determinants of spiritual health were identified through a scientific process. A statistically reliable and valid Spiritual Health Scale (SHS 2011) containing 114 items has been developed. Construct validity and test-retest reliability has been established. The 3 Domains are: Self-Evolution, Self-Actualization, and Transcendence. In this article, the process of self evolution in terms of "Wider Perspective" and "Nurturance-Art" have been captured through the Determinants like Commitment, Introspection, Honesty, Creativity, Contemplation, Prayer, Philanthropy, Extending Self, Empathy, Yoga and Exercise, Questioning Injustice, Aesthetics, Value for Time, and Being Away From Comparisons.

When there is mention of the word 'Evolution', immediately the first thought which comes to mind is about human evolution.

The history of human evolution is not very old, nevertheless the prehistoric fossil evidence suggests emergence of human race. Millions of years back, the fossil evidence pointed toward our ancestral lineage to great apes.

Through the process of evolution, we have reached to the present age. We do encounter in daily life, the evolution or to say revolution brought about by the humans in the field of science and medicine. This evolution has completely changed the way we perceive, think, and behave and the manner in which we live our life.

The purpose of evolution for the human race is mainly two folds: To live and propagate. If we do not evolve we will not survive. If we talk in terms of optimal health and our failure to evolve, it will leave us with disease adjusted life years (DALY). This group of people with DALY are steadily increasing, worldwide. However, the mortality at younger age due to faulty life style can certainly be prevented by bringing about change in life style.

The evolution in all spheres of life has reached almost at its zenith and now the research studies are focusing to find out as to how the life evolved on the planet and if there is any super power governing the planet, earth. This U turn after reaching moon is to sustain life by finding out the relationship of sentient and non sentient beings on the earth on one hand and on the other the spiritual elements and their role in health and happiness of people.

Spirituality - The 4 th dimension of health

Defining and measuring

The authors have conducted a research study to define and measure the spiritual health of an individual and have named it as Spiritual Health Scale (SHS 2011). This Scale is religion and culture free and measures the spiritual health of a common worldly person (Dhar, Chatuevedi, Nandan 2011). [1]

Available empirical evidence suggests the positive role of spirituality in coping with many physical and mental ailments and its role as a way of life to prevent illness, coping with illness, to some extent help in curing, its prognosis and rehabilitation as well.

WHO's health triangle

Physical, mental, and social dimensions of health

Health, as defined by World Health Organization (WHO), has been relied upon physical, mental, and social dimensions through the health triangle.

In this study, the 4 th dimension of health, "The spiritual health", has been defined, and a scale has been developed to measure the spiritual health of an individual.

Discussion

In the past decade, there has been scientific search for the relationship of the spirituality with intelligence, with emotions and also well-being. Measurement instruments have been developed to measure spiritual intelligence, [2] which is a spiritual correlate to intelligence quotient and emotional quotient. Like emotional quotient, spiritual quotient is assuming importance in scientific research and philosophical/psychological debates.

It is only for the 'last two decades or so', that modern system of medicine has started realizing the mind-body axis of the disease and health. [3] Before this, morbidity was related to body and its functions and accordingly, the focus was on the human body and physical surroundings. Perhaps this is the reason that no serious attempt has been made to develop a spiritual health scale per say, across the globe. The existing standard scales, which are to measure spiritual intelligence, spiritual well-being, and spiritual assessment, all are focusing on psychological, managerial, or emotional aspects of an individual, having spiritual influence, and not the relationship of spirituality with health. Though the standard tool on spiritual health does not exist, but research studies are available to show relationship between spiritual practices and health. Other standard tools developed on spirituality have bias of Judeo-Christian perspectives and above average peoples' perspective, are not comprehensive and do not have universally applicable contents. The Spiritual Health Scale (SHS 2011) is:

First comprehensive, standard scale on "Spiritual health".

Relevant for common worldly person.

Has universally applicable contents.

Religion and culture free.

Relevant for a believer, for an atheist, and for an agnostic as well.

Empirical evidence is available to indicate a direct relation between religious involvement, spirituality and positive health outcomes. Positive values, attitudes, beliefs and strength that one acquires through spiritual health practices contribute to the sense of well-being, health and happiness. Spiritual health practices have a positive correlation with survival, low blood pressure, less remission time from depression, less number of cigarettes smoked per day per week, less severe medical illness, better quality of life, cooperativeness, etc. [4]

Researchers further suggest a positive relation between spiritual well-being/practices and positive health outcomes, like greater self-confidence, assertiveness and fewer symptoms of anxiety and depression. Spiritual well-being is reported to be positively related with self-ratings of physical health and vitality. Spiritual health/wellness is positively related with adjustment to dialysis treatment and cancer induced pain. [5]

Studies in USA indicate that patients and physicians would like to consider spiritual health factors in the medical care and its assessment too. Studies in USA indicate a positive correlation between patients' spiritual/religious commitments and health outcomes and would also like physicians to consider these factors in their medical care practice. Subsequently, they have suggested spiritual health assessment as a first step in medical care practice. A formal tool called HOPE has been designed for the purpose. Here H stands for sources of hope, comfort, strength, meaning, peace, love connections; O stands for role of organized religion for the patients; P stands for personal spirituality and practices; and E stands for effects on medical care. [6]

Research indicates a close relationship between love for God or feeling of being loved by some Higher Reality with greater self-esteem, higher levels of self-efficacy, sense of mastery, less depression, less physical disability, and greater self-rated health. The John Templeton Foundation, USA has invested on more than 24 research studies on forgiveness. [7] 'Unconditional love is the most powerful stimulant of the immune system - the truth is; love heals'. [8] In his remarkable program for cancer patients, he facilitated them in experiencing love with other emotions like forgiveness, which 'mobilize the immune system and engender health'.

"Renewing the spiritual dimension provides leadership to your life-I find renewal in daily prayerful meditation-immersion in great literature or great music-harmony and rhythm of nature-personal mission statement-to promote the welfare and good of other people and to be genuinely happy for other people's success". [9]

Ayurveda, an ancient healing system of India also has the central philosophy that physical health cannot be achieved without emotional, mental, and spiritual health. Thus, Ayurveda, being a Science of Longevity of man, focuses on improving the quality of life. As per Ayurveda, health is not mere absence of disease but is a state of balance in which doshas (humors), agni (metabolic fire), and malas (products of excretion) are in state of equilibrium and the cheerful state of soul, mind intellect, and sense organs is designated as health.

Referring to Ayurveda healthy lifestyle in which social activities are claimed to be best medicine for good mental and spiritual health, Hebbar says, "if you are lonely, selfish person who cares only about you, yourself and your family and friends and your home, etc. when the people near to you hurt you it hurts the most. But, if you are socially active, it is very easy to find the answer for the questions like: For what I should live in this world? For what would reason, should I continue living? Having blessed with this beautiful gift of life, having absorbed so much of love and happiness from our beloved people, it is our right and duty to give it back".[10]

In the study under reference, the 4 th Dimension of health, the Spiritual Health was defined and measured through the cognitive, behavioral, and affective aspects of the personality.

Three Domains of spiritual health named as: "Self-Evolution", "Self-Actualization", and "Transcendence" have been evolved in this study. For each Domain, 2 Constructs have been identified and against each Construct, there are Determinants, which qualify for the Construct. The items of the Scale (SHS 2011) capture the interpretation of the Domains in general, and that of Constructs and Determinants in particular [Table 1].

The weights obtained by the 3 Domains through Regression Analysis indicates that the Domain of Self-Evolution was found to be more adaptable at cognitive, affective and behavioral levels of functioning by the respondents whereas Self-Actualization was found to be comparatively lesser and the Transcendence was still lesser.

The highest weight obtained by the Domain of Self-Evolution could be possibly because it focuses relatively on grosser aspects of life - physical, mental, and social.

In this article, the effort is to deal with the first Domain, that is, Self-Evolution, and how it has been contemplated in the study to achieve it. It has already been discussed earlier that few Determinants have been identified and by consciously working toward gaining control over most of these Determinants, there is possibility to evolve spiritually.

Each individual has different ways of looking at one's duties and responsibilities. A spiritually evolved person will have positive views toward one's commitment for these attributes. As we all know that evolution is a process and not an event. Through this process of self-evolution, the individual makes conscious and constant efforts to cultivate the habit of commitments to once duties, through introspection and honesty, indulges in creativity through contemplation for larger human welfare, extending beyond self with empathy to question injustice along with appreciation of work of art and music. In these efforts the prayers to the object of one's faith can help attaining the aim of self-evolution. The process is only complete when these Determinants of self evolved person become the way of life or is the life style of a self evolved person, in other words, living effortlessly. The core concept lies in the fact that the process of evolution is initiated by extending the self for the welfare of others.

Similarly, for self-evolution, it is imperative to introspect, reflect on self and honestly explore the qualities and habits, which impair self-renewal and apply the fundamental principles which can be instrumental in this spiral process.

Another aspect of one's personality, which helps in self-evolution, is to intelligently and imaginatively work toward contributing usefully to the society without thinking much about the rewards in return and safely and consciously working for putting one's creative abilities to use for others.

Being creative needs contemplation to understand the deeper meaning of life with the understanding of the fact that the joy comes from within and lasting happiness cannot come from external factors. An attitude of appreciating nature and protecting it gives an insight that nature always gives to all sentient beings equally, based on needs and this becomes our duty to preserve the nature. This understanding of natural gifts to living being also gives an insight to work towards the common welfare. When we work toward the welfare of others, we should try to analyze the fact that the happiness of self lies in the happiness of others, when we talk about in terms of evolving the self beyond the self-centered approach and cultivate to value the humanitarian principles over and above the cultural beliefs.

When one rises beyond the self, and opens up for the society, the natural outcome is the realization of the fact that one's behavior is guided by the principles of "do onto others as you want others do onto you". This attitude culminates in to feeling of pain, suffering when others are placed in similar situations and indulge in Philanthropy by supporting the deserving.

With the development of sense of empathy for others, the natural quality, which one develops, is to raise the voice for injustice that includes raising your voice against the orthodox religious and cultural beliefs, which are detrimental to human values.

In order to tread the path of self-evolution and to pursue the same persistently, consistent efforts are required at cognitive, affective and behavioral levels. It is a well known fact that only healthy body can have the healthy mind. Ancient texts have emphasized that the body is the vehicle through which one can attain the ultimate aim of evolution of living a life of a human being. To this effect, to maintain, a good physical, mental, and social health becomes an essential part of human endeavors.

When an individual is on the path of self-evolution, it becomes natural for him to be inclined and attracted toward the means of gaining pleasure from music, poetry, and paintings in which one sees the expression of evolving self and evolution of the creator of these pieces of aesthetic importance.

For a person on the path of self-evolution, it comes naturally to be conscious about the "time" and value its importance. The time once lost never comes back again, becomes the important understanding in life. Such a self evolved person does not waste his time in unhealthy comparisons with others.

In these efforts, the prayers to the object of one's faith can help attaining the aim of self-evolution, the process is only complete when these Determinants of a self-evolved person become the way of life or is the life style of a self-evolved person, in other words living effortlessly. The core concept lies in the fact that the process of evolution is initiated by extending the self for the welfare of the needy and deserving and work for inner happiness.

Conclusion

There is an urgent call for health professionals in India and across the Globe to focus on self-evolutionary and self-renewal aspects of spiritual health. They need to carve out a path for empirical investigations in this aspect of health, its measurement and subsequently its application in various health settings for better health outcome, ensuring a higher quality of life and reducing economic burden. It can be applied as an integrated preventive, diagnostic, treatment, prognostic, and rehabilitative or developmental tool in clinical settings, psychotherapeutic clinics, counseling centers, universities, workplaces so on and so forth.

Development of the spiritual health scale (SHS 2011) is a milestone in this direction.